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66/12/2002 08:44 2094671118 AGE STOCKTON PAGE 02 <br /> CITY OF STOCKTON r, F <br /> PUBLIC WORKS DEPARTMENT l) <br /> APPLICATION FORENCROACHMENTON PUBLIC RIGHT-OF-WAY <br /> Applicants Name Ar_VoO).d Gioobwjp►1Date S�� ��- APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) P-09 <br /> ��__ (/ Subject to the General Provislons and Special Conditions,and all <br /> Address 773 1 .s Q,ZV P-0 Phone (�f work must conform to the project's approved Storm Water Pollution <br /> A_ ZIP Prevention Plan or the City of Stockton Storm Water Pollution <br /> City 5�t State {� Prevention Maintenance Staff Guide,whichever is applicable. <br /> /� <br /> Location of Proposed Work,etc. t DT-r'6- QJ 6c& <br /> `0.� eel 0 2 <br /> Owner/Contractor Address {tom Z /"• C 1/' ✓1/ a By r � Date <br /> Estimating Starting Date Completion Date Fj" It-0 Z- Permit Expiration Date e ^el`o <br /> 1 (or l hereby apply for an Encroachment Permit to arty out the following work: a n e- <br /> 6A P-'Nl !nabk pne OP <br /> s <br /> ALL TWO WORKING <br /> DAYS FORE YOU DIG <br /> ONDERGROUND SERVICE Al PRT <br /> Tile above named applicant hereby raqueala per i.. <br /> PERMIT FEE............................$ <br /> '50 Additional Footage Fee............ $ <br /> Trench Fee---------- -------------- ----- $ <br /> Sewer Tap Deposit....................$ <br /> TOTAL DEPOSIT.........$ 2 r <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions- <br /> Ic.' e. c lorsud'_:�' eir�e_ <br /> ��'ftr �,,,4•,rk Am ff�Nt Cc�v.IoaleAW 61""h �v1fP/" c3 S�w <br /> Show aketch above of refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances, resolutions, <br /> Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements. Fallure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> harmless against any and all losses,Costs,or damages resulting from Injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LFSS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,A$IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENC31NEER AT(209)937.8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT B FORE SIGNING. <br /> Signed: Phone: _ <br /> tst-Pennittee{whito) 2nd-Inspeotlon(pink) 3rd-File(yellow) 4th-Finance(white) <br />